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08227040119 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> 104) <br /> callfamla IntegramdtWaste Management Board Survey Form - Page 1 I 1 -1088387 <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Ll ti 13 =_iFf - OI <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> Local 'c If Ref erral,choose referral type(Fill one) <br /> Identifier: LV 0-k�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �— Inspected By Inspector <br /> Physical Address I <br /> 13191 - <br /> ( o I I ILj <br /> I_133340 40 ate I <br /> Street <br /> ib&4zi Y-) Inspection Date <br /> wt, JO(Srafe ZIP Code J Time In Time Out _ <br /> Business Rep Title I O AM O AM <br /> IOPM I J'� QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I' O (Fill one only) .(Fill all that appty) (Fill all that apply) (Fill all that apply) <br /> t t ®Active ®Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> _. O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) -- <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ®Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments ,D 0Ueof p In -0- on `1 u,-,s daft no Qs 1,,Q �o l rLq " f lj, <br /> � t `rh^�S `� D� �e SS (,uCc s f 2 &re-,s "k fZranhofl �`T eel Ti✓�. <br /> Th✓o ices �epfi on F,.I fay re vi eur' NO J►'o( .s �w`F� <br /> Inspection Form Included:Q / <br /> Comments Included:Q '-� (og- `qc 10 <br /> Business Rep's Signature - Phone Number Inspector's S nature Phone Number . <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E I X A M P 1 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br />